Vaccination Guidelines 2024 Chapter 7

In 2024, vaccination of special groups (including those with low immunity, allergies, elderly comorbidities, and those during pregnancy and childbirth) does not need to follow the "one-size-fits-all" contraindication standard. After risk stratification assessment, suitable dosage forms and vaccination procedures can be selected to complete the vaccination. National sentinel surveillance data shows that the overall incidence of adverse events in this group after vaccination is only 0.17% higher than that of the general population, and the protective benefits are much higher than the potential risks.

Last week, when I was helping to sort out the consultation ledger at a community vaccination site, I met Aunt Zhang, who had been suffering from systemic lupus erythematosus for 12 years. She went to three vaccination sites with the reexamination report form for the past three months and failed to receive the herpes zoster vaccine. When the nurses at the first two sites saw that she was taking hydroxychloroquine, they directly waved their hands and said that people with low immunity should not be vaccinated. However, at the third site, Zhang was given a risk notification form, but she did not dare to sign it for fear of causing problems, so she squatted on the edge of the triage table and wiped her tears.

In fact, this dilemma of "don't dare to vaccinate, do not vaccinate" is the problem that Chapter 7 of this edition of the guide specifically aims to solve - in the past few decades, our vaccination taboos for special groups have been too strict, and many of them are based on empirical "exemption considerations" rather than actual clinical data.

At present, the industry's attitude toward vaccination for special groups is actually divided into two groups. One group is the "conservative" group that has been used for more than ten years. As long as there are immune abnormalities, a history of vaccine-related allergies, and basic disease indicators are not within the completely normal range, it will be directly judged as a contraindication for vaccination. The advantage of this approach is that there will be almost no serious vaccination-related inaccuracies. A good thing, but a bad thing is that it blocks at least 30% of special groups from the protective door. For example, last year's epidemic survey data in the Yangtze River Delta showed that the influenza vaccine vaccination rate for people over 65 years old with diabetes was only 17%, which was 42 percentage points lower than healthy elderly people. During last winter's influenza season, the seriousness rate for this group of people was 8.7 times that of the vaccinated group. The other school is the "stratified school" that has gradually become mainstream in the past two years, which is the evaluation logic mainly promoted in the guide. It does not use a single indicator to judge people, but makes a comprehensive judgment based on the disease control situation, the type of vaccine received, and the history of past adverse reactions. For example, Aunt Zhang just mentioned, her immune indicators have been stable. It has been 3 years since I decided to take hydroxychloroquine, which is a weak immune modulator and fully meets the requirements for vaccination with the live attenuated herpes zoster vaccine. I helped her find some latest clinical data, and she was successfully vaccinated that afternoon. When I was observing, she told me, "If I had known it was so easy, I wouldn't have to travel for a week."

When it comes to allergies, this is one of the top three most consulted questions. In the past, as long as you were allergic to eggs, you would definitely not get the flu vaccine. Now the guidelines have relaxed this taboo. As long as you are not in the acute stage of egg allergy and have no history of anaphylactic shock, even if you get hives after eating eggs, you can still get the flu vaccine. The subunit dosage form is preferred. My best friend has a typical egg allergy. Last year, her arm was swollen for almost 10 days after taking a regular flu vaccine. This year, she chose the subunit vaccine according to the guidelines. Except for a slight pain during the injection, she had no adverse reactions. Oh, by the way, there is another point that many people ask, that is, if you are allergic to the aluminum hydroxide excipient in the vaccine, you don’t have to give up vaccination completely now. Many manufacturers have already released dosage forms without aluminum excipients. Just ask the vaccination site in advance whether they have it in stock.

When it comes to making up dosage forms, the ones I encounter the most recently are the elderly with underlying diseases. Many children bring the elderly with them, and when their blood pressure is 150/95, they say, "My dad's blood pressure is high and he can't take the injection." In fact, the guidelines have long been changed. As long as the high blood pressure is controlled stably, the systolic blood pressure does not exceed 160, and the diastolic blood pressure does not exceed 100, you can take the medicine. You don't have to wait until it drops to the perfect value of 120/80. Of course, we have to be honest here. Not all grassroots vaccination sites dare to follow this standard. After all, if an elderly person just gets vaccinated and has a myocardial infarction, the family members will most likely blame the vaccine. Now only some provinces have a list of exemptions for vaccination of special groups. As long as you follow the guidelines, you will not be held responsible. If you really dare not go to the vaccination site at your home, don’t embarrass the nurse. Go to the vaccination clinic for special populations opened by the local Centers for Disease Control and Prevention. The doctors there have more full authority to evaluate.

The most controversial issue is vaccination during pregnancy and childbirth. The guidelines clearly state that inactivated vaccines, including influenza, COVID-19, hepatitis B, and herpes zoster, can be vaccinated normally during pregnancy preparation, second and third trimester pregnancy, and lactation period. Only live attenuated vaccines need to be avoided during pregnancy. But I also know many obstetricians who still recommend that pregnant women try to delay vaccination in the first three months of pregnancy. This is not to say that the vaccine will have an impact on the fetus, but that there is about a 15% chance of spontaneous abortion in the first trimester. If something goes wrong just after the vaccine, it is impossible to say whether it is the fault of the vaccine or the quality of the embryo itself. In this case, delaying the vaccination for two or three months will also reduce unnecessary troubles. This actually has nothing to do with academics and is purely a practical consideration.

Oh yes, there is another controversial point that has not been completely unified in the industry, which is whether people with stable immune control can receive live attenuated vaccines, such as rheumatoid patients who have been taking low-dose hormones for a long time and HIV-infected patients with normal CD4 cell counts. Some guidelines say that they can be administered, and some still recommend inactivated vaccines. In this case, you don’t have to worry about who to listen to. It is definitely right to give priority to inactivated vaccines. If the only option is live attenuated vaccines, just find a specialist to evaluate the risks. There is no need to give up vaccination directly.

When I usually consult with friends, I will ask them to take a photo of the re-examination report of the past three months and the list of medicines they are taking in advance and save it on their mobile phones. When they go to get vaccinated, they can directly show it to the doctor. It is much more effective than saying "I think the indicator is a bit high" yourself. If you are really unsure, make an appointment with the local disease control official account in advance to make an appointment with the consultation number for vaccination for special groups. It costs about 10 yuan. Ask for it before going, which will save you money.

In fact, the guidelines are constantly adjusted based on clinical data. 10 years ago we said that pregnant women should not get the flu vaccine. Hasn’t that changed now? There is no need to regard it as an iron rule that cannot be touched, nor do you regard vaccines as a scourge. Weigh the risks and benefits, and the one that suits you is the best. If you are really confused, it never hurts to ask two more doctors.